Concerns of the anesthesiologist: anesthetic induction in severe sepsis or septic shock patients

Septic patients portray instable hemodynamic states because of hypotension or cardiomyopathy, caused by vasodilation, thus, impairing global tissue perfusion and oxygenation threatening functions of critical organs. Therefore, it has become the primary concern of anesthesiologists in conducting anesthesia (induction, maintenance, recovery, and postoperative care), especially in the induction of those who are prone to fall into hemodynamic crisis, due to hemodynamic instability. The anesthesiologist must have a precise anesthetic plan based on a thorough preanesthetic evaluation because many cases are emergent. Primary circulatory status of patients, including mental status, blood pressure, urine output, and skin perfusion, are necessary, as well as more active assessment methods on intravascular volume status and cardiovascular function. Because it is difficult to accurately evaluate the intravascular volume, only by central venous pressure (CVP) measurements, the additional use of transthoracic echocardiography is recommended for the evaluation of myocardial performance and hemodynamic state. In order to hemodynamically stabilize septic patients, adequate fluid resuscitation must be given before induction. Most anesthetic induction agents cause blood pressure decline, however, it may be useful to use drugs, such as ketamine or etomidate, which carry less cardiovascular instability effects than propofol, thiopental and midazolam. However, if blood pressure is unstable, despite these efforts, vasopressors and inotropic agents must be administered to maintain adequate perfusion of organs and cellular oxygen uptake.